Esophageal Cancer
Esophageal Cancer
Esophageal Cancer
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Name of Student: Sakthiswaran Rajasekar
Group N. 4
Medical Faculty
KURSK 2010
is malignancy of the esophagus. There are various subtypes, primarily
adenocarcinoma (approx. 50-80% of all Esophageal cancer) and squamous cell cancer.
Squamous cell cancer arises from the cells that line the upper part of the esophagus.
Adenocarcinoma arises from glandular cells that are present at the junction of the esophagus and
stomach.[1] Esophageal tumors usually lead to dysphagia (difficulty swallowing), pain and other
symptoms, and are diagnosed with biopsy. Small and localized tumors are treated surgically with
curative intent. Larger tumors tend not to be operable and hence are treated with palliative care;
their growth can still be delayed with chemotherapy, radiotherapy or a combination of the two.
In some cases chemo- and radiotherapy can render these larger tumors operable. Prognosis
depends on the extent of the disease and other medical problems, but is fairly poor.[2]
Esophageal cancers are typically carcinomas which arise from the epithelium, or surface lining,
of the esophagus. Most esophageal cancers fall into one of two classes: squamous cell
carcinomas, which are similar to head and neck cancer in their appearance and association with
tobacco and alcohol consumption, and adenocarcinomas, which are often associated with a
history of gastroesophageal reflux disease and Barrett's esophagus. A general rule of thumb is
that a cancer in the upper two-thirds is a squamous cell carcinoma and one in the lower one-third
is a adenocarcinoma.
Dysphagia (difficulty swallowing) and odynophagia (painful swallowing) are the most common
symptoms of esophageal cancer. Dysphagia is the first symptom in most patients. Odynophagia
may also be present. Fluids and soft foods are usually tolerated, while hard or bulky substances
(such as bread or meat) cause much more difficulty. Substantial weight loss is characteristic as a
result of poor nutrition and the active cancer. Pain, often of a burning nature, may be severe and
worsened by swallowing, and can be spasmodic in character. An early sign may be an unusually
husky or raspy voice.
The presence of the tumor may disrupt normal peristalsis (the organised swallowing reflex),
leading to nausea and vomiting, regurgitation of food, coughing and an increased risk of
aspiration pneumonia. The tumor surface may be fragile and bleed, causing hematemesis
(vomiting up blood). Compression of local structures occurs in advanced disease, leading to such
problems as upper airway obstruction and superior vena cava syndrome. Fistulas may develop
between the esophagus and the trachea, increasing the pneumonia risk; this condition is usually
heralded by cough, fever or aspiration.[2]
If the disease has spread elsewhere, this may lead to symptoms related to this: liver metastasis
could cause jaundice and ascites, lung metastasis could cause shortness of breath, pleural
effusions, etc.
There are a number of risk factors for esophageal cancer. Some subtypes of cancer are linked to
particular risk factors:
^ Age. Most patients are over 60, and the median in US patients is 67.
^ Sex. It is more common in men.
^ 2eredity. It is more likely in people who have close relatives with cancer.
^ Tobacco smoking and heavy alcohol use increase the risk, and together appear to increase
the risk more than either individually.
^ uastroesophageal reflux disease (uERD) and its resultant Barrett's esophagus increase
esophageal cancer risk due to the chronic irritation of the mucosal lining
(adenocarcinoma is more common in this condition, while all other risk factors
predispose more for squamous cell carcinoma).
^ 2uman papillomavirus (2PV)
^ Corrosive injury to esophagus by swallowing strong alkalines (lye) or acids.
^ Particular dietary substances, such as nitrosamine.
^ A medical history of other head and neck cancers increases the chance of developing a
second cancer in the head and neck area, including esophageal cancer.
^ Plummer-Vinson syndrome (anemia and esophageal webbing)
^ Tylosis and 2owel-Evans syndrome (hereditary thickening of the skin of the palms and
soles).
^ Radiation therapy for other conditions in the mediastinum.
^ Celiac disease predisposes towards squamous cell carcinoma.
^ Obesity increases the risk of adenocarcinoma fourfold. It is suspected that increased risk
of reflux may be behind this association.
^ Drinking hot brewed tea
^ Alcohol consumption in individuals predisposed to alcohol flush reaction
^ Achalasia
V
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Although an occlusive tumor may be suspected on a barium swallow or barium meal, the
diagnosis is best made with esophagogastroduodenoscopy (EuD, endoscopy); this involves the
passing of a flexible tube down the esophagus and visualising the wall. Biopsies taken of
suspicious lesions are then examined histologically for signs of malignancy.
Additional testing is usually performed to estimate the tumor stage. Computed tomography (CT)
of the chest, abdomen and pelvis, can evaluate whether the cancer has spread to adjacent tissues
or distant organs (especially liver and lymph nodes). The sensitivity of CT scan is limited by its
ability to detect masses (e.g. enlarged lymph nodes or involved organs) generally larger than
1 cm. FDu-PET (positron emission tomography) scan is also being used to estimate whether
enlarged masses are metabolically active, indicating faster-growing cells that might be expected
in cancer. Esophageal endoscopic ultrasound (EUS) can provide staging information regarding
the level of tumor invasion, and possible spread to regional lymph nodes.
The location of the tumor is generally measured by the distance from the teeth. The esophagus
(25 cm or 10 inches long) is commonly divided into three parts for purposes of determining the
location. Adenocarcinomas tend to occur distally and squamous cell carcinomas proximally, but
the converse may also be the case.
Most tumors of the esophagus are malignant, only about 0.5% are benign. A very small
proportion (under 10%) is leiomyoma (smooth muscle tumor) or gastrointestinal stromal tumor
(uIST). Malignant tumors are generally adenocarcinomas, squamous cell carcinomas, and
occasionally
. The latter share many properties with small-cell lung cancer,
and are relatively sensitive to chemotherapy compared to the other types.
?
Self-expandable metallic stents are used for the palliation of esophageal cancer.
Esophageal cancer affecting the lower esophageus. Insets show the tumor in more detail both
before and after placement of a stent.
The treatment is determined by the cellular type of cancer (adenocarcinoma or squamous cell
carcinoma O other types), the stage of the disease, the general condition of the patient and other
diseases present. On the whole, adequate nutrition needs to be assured, and adequate dental care
is vital.
If the patient cannot swallow at all, a stent may be inserted to keep the esophagus patent; stents
may also assist in occluding fistulas. A nasogastric tube may be necessary to continue feeding
while treatment for the tumor is given, and some patients require a gastrostomy (feeding hole in
the skin that gives direct access to the stomach). The latter two are especially important if the
patient tends to aspirate food or saliva into the airways, predisposing for aspiration pneumonia.
Esophagectomy is the removal of a segment of the esophagus; as this shortens the length of the
remaining esophagus, some other segment of the digestive tract (typically the stomach or part of
the Colon or jejunum]) is pulled up to the chest cavity and interposed. If the tumor is
unresectable or the patient is not fit for surgery, palliative esophageal stenting can allow the
patient to tolerate soft diet.
Types of esophagectomy:
^ Thoracoabdominal approach- which opens the abdominal and thoracic cavities together.
^ Two stage Ivor Lewis (also called Lewis-Tanner) approach- with an initial laparotomy
and construction of a gastric tube, followed by a right thoracotomy to excise the tumor
and create an esophagogastric anastomosis.
^ Three stage McKeown approach- where a third incision in the neck is made to complete
the cervical anastomosis.
Endoscopic Therapy for Localized Disease There is accumulating data that endoscopic therapy is
a safe, less invasive, and effective therapy for very early esophageal cancer. The candidates for
endoscopic therapy are Stage 1 patients with tumors invading into the lamina propria (T1
mucosal) or submucosa (T1 submucosal) that do not have regional or distant metastasis. Patients
with carcinoma in-situ or high-grade dysplasia can also be treated with endoscopic therapy.
Submucosa cancers with increased risk of nodal metastases may not be as amenable to curative
therapy.
The two forms of endoscopic therapy that have been used for Stage 0 and I disease are
endoscopic mucosal resection (EMR) and mucosal ablation using photodynamic therapy , Nd-
YAu laser, or argon plasma coagulation.
EMR Endoscopic Mucosal Resection has been advocated for early cancers (that is, those that are
superficial and confined to the mucosa only) and has been shown to be a less invasive, safe, and
highly effective nonsurgical therapy for early squamous cell esophageal cancer. Preliminary
reports also suggest its safety and efficacy for early adenocarcinoma arising in Barrett¶s
esophagus. The prognosis after treatment with endoscopic mucosal resection is comparable to
surgical resection. This technique can be attempted in patients, without evidence of nodal or
distant metastases, with differentiated tumors that are slightly raised and less than 2 cm in
diameter, or in differentiated tumors that are ulcerated and less than 1 cm in diameter. The most
commonly employed modalities of endoscopic mucosal resection include strip biopsy, double-
snare polypectomy, resection with combined use of highly concentrated saline and epinephrine,
and resection using a cap.
The strip biopsy method for endoscopic mucosal resection of esophageal cancer is performed
with a double-channel endoscope equipped with grasping forceps and snare. After marking the
lesion border with an electric coagulator, saline is injected into the submucosa below the lesion
to separate the lesion from the muscle layer and to force its protrusion. The grasping forceps are
passed through the snare loop. The mucosa surrounding the lesion is grasped, lifted, and
strangulated and resected by electrocautery. The endoscopic double-snare polypectomy method
is indicated for protruding lesions. Using a double-channel scope, the lesion is grasped and lifted
by the first snare and strangulated with the second snare for complete resection.
Endoscopic resection with injection of concentrated saline and epinephrine is carried out using a
double-channel scope. The lesion borders are marked with a coagulator. 2ighly concentrated
saline and epinephrine are injected (15±20 ml) into the submucosal layer to swell the area
containing the lesion and elucidate the markings. The mucosa outside the demarcated border is
excised using a high-frequency scalpel to the depth of the submucosal layer. The resected
mucosa is lifted and grasped with forceps, trapping and strangulating the lesion with a snare, and
then resected by electrocautery.
A fourth method of endoscopic mucosal resection employs the use of a clear cap and prelooped
snare inside the cap. After insertion, the cap is placed on the lesion and the mucosa containing
the lesion is drawn up inside the cap by aspiration. The mucosa is caught by the snare and
strangulated, and finally resected by electrocautery. This is called the "band and snare" or "suck
and cut" technique. The resected specimen is retrieved and submitted for microscopic
examination for determination of tumor invasion depth, resection margin, and possible vascular
involvement. The resulting "ulcer" heals within 3 weeks.
Although most lesions treated in the esophagus have been early squamous cell cancers,
endoscopic snare resection can also be used to debulk or completely treat polypoid dysplastic or
malignant lesions in Barrett¶s esophagus. In a preliminary report from uermany, EMR was
performed as primary treatment or adjunctive therapy following photodynamic therapy for early
adenocarcinomas in Barrett's esophagus. The "suck and cut" technique (with and without prior
saline injection) was used as well as the "band and cut" technique. Although all tumors were
resected without difficulty, 12.5% developed bleeding (which was managed successfully by
endoscopic therapy). Eighty-one percent of the lesions were completely resected. The other
lesions were also treated with other endoscopic techniques. While this report suggests it is
feasible to completely resect local, circumscribed, early adenocarcinomas arising in Barrett's
esophagus, the relative safety and efficacy of EMR in conjunction with photodynamic therapy is
unknown.
The major complications of endoscopic mucosal resection include postoperative bleeding and
perforation and stricture formation. During the procedure, an injection of 100,000 times diluted
epinephrine into the muscular wall, along with high frequency coagulation or clipping can be
applied to the bleeding point for hemostasis. It is important to administer acid-reducing
medications to prevent postoperative hemorrhage. Perforation may be prevented with sufficient
saline injection to raise the mucosa containing the lesion. The "non-lifting sign" and complaints
of pain when the snare strangulates the lesion are contrainidications of EMR. When perforation
is recognized immediately after a procedure, the perforation should be closed by clips. Surgery
should be considered in cases of endoscopic closure failure. The incidence of complication range
from 0±50% and squamous cell recurrence rates range from 0±8%.
Laser therapy is the use of high-intensity light to destroy tumor cells; it affects only the treated
area. This is typically done if the cancer cannot be removed by surgery. The relief of a blockage
can help to reduce dysphagia and pain. Photodynamic therapy (PDT), a type of laser therapy,
involves the use of drugs that are absorbed by cancer cells; when exposed to a special light, the
drugs become active and destroy the cancer cells.
Chemotherapy depends on the tumor type, but tends to be cisplatin-based (or carboplatin or
oxaliplatin) every three weeks with fluorouracil (5-FU) either continuously or every three weeks.
In more recent studies, addition of epirubicin (ECF) was better than other comparable regimens
in advanced nonresectable cancer.[19] Chemotherapy may be given after surgery (adjuvant, i.e. to
reduce risk of recurrence), before surgery (neoadjuvant) or if surgery is not possible; in this case,
cisplatin and 5-FU are used. Ongoing trials compare various combinations of chemotherapy; the
phase II/III REAL-2 trial ± for example ± compares four regimens containing epirubicin and
either cisplatin or oxaliplatin and either continuously infused fluorouracil or capecitabine.
Radiotherapy is given before, during or after chemotherapy or surgery, and sometimes on its own
to control symptoms. In patients with localised disease but contraindications to surgery, "radical
radiotherapy" may be used with curative intent.
Patients are followed up frequently after a treatment regimen has been completed. Frequently,
other treatments are necessary to improve symptoms and maximize nutrition.
In general, the prognosis of esophageal cancer is quite poor, because so many patients present
with advanced disease: The overall five-year survival rate (5YSR) is less than 5%. Individualized
prognosis depends largely on stage. Those with cancer restricted entirely to the esophageal
mucosa have about an 80% 5YSR, but submucosal involvement brings this down to less than
50%. Extension into the muscularis propria (muscular layer of the esophageus) has meant a 20%
5YSR and extension to the structures adjacent to the esophagus results in a 7% 5YSR. Patients
with distant metastases (who are not candidates for curative surgery) have a less than 3% 5YSR.
Esophageal cancer is a relatively rare form of cancer, but some world areas have a markedly
higher incidence than others: China, Iran, Iceland, India and Japan, as well as the United
Kingdom, appear to have a higher incidence, as well as the region around the Caspian Sea.
The American Cancer Society estimates that during 2007, approximately 15,560 new esophageal
cancer cases will be diagnosed in the United States.
The esophageal cancer incidence and mortality rates for people of African-American descent
have been higher than the rate for Caucasians. According to the NCI, incidence of
adenocarcinoma of the esophagus, which is associated with Barrett's esophagus, is rising in the
United States. This type is more common in Caucasian men over the age of 60.
Multiple reports indicate that esophageal adenocarcinoma incidence has increased during the
past 20 years, especially in non-2ispanic white men. Esophageal adenocarcinoma age-adjusted
incidence increased in New Mexico from 1973 to 1997. This increase was found in non-2ispanic
whites and 2ispanics and became predominant in non-2ispanic whites.
^ NCI Esophageal Cancer 2ome Page
^ MedlinePlus: Esophageal Cancer
^ Esophageal Cancer From Cancer Management: A Multidisciplinary Approach
^ Learn More about Esophageal Cancer
^ Oesophageal Cancer at Cancer Research UK
^ Oesophageal Cancer Facts/ Resources (BBC) (Last updated: 30 January 2004)